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General NPI Number Information
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NPI Number | 1780930263
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Entity Type | Organization
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Legal Business Name | NORTH AVENUE ADVANCED DENTAL CENTER
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 08/02/2012
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Provider Practice Location Address
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Address Line | 2260 NORTH AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06604-2413
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Country | US
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Telephone | 203-853-2732
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Fax | 203-612-9781
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Provider Business Mailing Address
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Address Line | 2260 NORTH AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06604-2413
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Country | US
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Telephone | 203-853-2732
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Fax | 203-612-9781
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Authorized Official
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Title or Position | OWNER
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Name | DR. LUIS M BREA
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Credential | DDS
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Telephone | 203-853-2732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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